To analyze the correlation between phenotype/genotype to selected antiretroviral agents and short-term change in viral load upon discontinuation of a single antiretroviral agent from a failing regimen, one drug in a failing multidrug regimen is withdrawn for a limited period of time, and then restored. By monitoring changes in both viremia and genotype (by the limiting dilution assay), we can discern whether the drug was contributing to partial suppression of virus, and also determine which mutations are associated with resistance to that drug, and their effect on both replication of the virus and resistance to the drug. In collaboration with Dr. Vinay Pathak, we have begun to analyze the entire RT sequence to determine whether additional changes in the RNAse H portion of RT are associated with partial drug suppression. With Dr. Anuradha Ganesan we have initiated a new site for this protocol at the National Naval Medical Center. The need for new antiviral agents continues, and identification of cellular pathways participating in HIV-1 maturation by E. Freed in the DRP and others have suggested novel strategies to inhibit virus replication by disrupting host-viral interactions required for virion maturation. Specifically, we are studying the cholesterol lowering agent, atorvastatin, which reduces viral yield and infectivity in vitro by reducing cholesterol in lipid rafts required for HIV-1 maturation. Previous observations by HVIB and others have yielded conflicting evidence on the potential antiviral benefit of statin therapy. In collaboration with National Naval Medical Centers in Bethesda and San Diego (Drs. Ganesan and Crum-Clanfione) and with NIH Clinical Center (Masur), the HVIB conducted the first randomized, placebo-controlled trial of atorvastatin in HIV-1 infection (Protocol 06-I-0197). This study included a detailed analysis of host and viral genetics as well as extensive immunophenotyping;as a result we investigated the overall utility of the statin approach in inhibiting HIV-1 replication, and studied the genetic correlates associated with success or failure the utility of this approach and identify immune effects of statin therapy. We found that 80 mg Atorvastatin therapy for 8 weeks duration did not specifically decrease HIV-1 RNA levels, but did affect immunophenotyping profiles with significant decreases in proportion of CD8CD38 cells in peripheral blood (Ganesan et al., submitted). These studies illustrate the complex interplay between immune and viral effects during HIV infection, and demonstrate the ability of statin therapy to decrease cellular immune activation parameters independently of any effect on viremia per se. We are currently analyzing additional markers of inflammation (e.g., IL-6, D-dimer) for effects of statin therapy on soluble markers of inflammation. Several clinical groups at NIH (I. Sereti, NIAID;J. Mican, NIAID) have engaged DRP investigators to collaborate in analyzing resistance profiles arising in patients on standard and experimental therapy (Porter, B.O., et al., 2009). In addition, the HVIB serves as a primary resource for interpretation of genotypic and phenotypic information for a number of protocols, notably protocol 95-I-0072 (J. Mican, NIAID PI, F. Maldarelli, Associate Investigator), used in training of infectious disease fellows, and for local referral of difficult cases. These interactions support mentoring of trainees and also result in new and clinically relevant information regarding HIV and antiviral therapy. In collaboration with NIAID (J. Mican, A. Pau), HVIB investigators recently characterized a previously unrecognized interaction between the antiretroviral ritonavir and local epidural hydrocortisone preparations. Understanding the host metabolic contribution to antiretroviral drug metabolism is an integral aspect of understanding such interactions, and HVIB participates in active research in this area (Robertson, et al., 2009). In addition, with J.Mican and H.C. Lane (NIAID), we are in the process of characterizing a new drug insertion mutation in Subtype C reverse transcriptase with novel phenotypic resistance properties. We have also participated in post-hoc analyses of resistance profiles of individuals enrolled in NIAID-South Africa collaborative protocols of antiretroviral therapy (Phidisa II). We have compared emergence of mutations in a cohort of over 1700 patients enrolled in a randomized study comparing NNRTI and PI containing regimens. A direct clinical outcome of the expertise gained in these studies has been in evaluating cases of occupational exposure to HIV that have occurred in NIH clinical and veterinary settings. Exposure to drug resistant virus as well as novel HIV and recombinant SHIV experimental viruses requires detailed considerations for post exposure prophylaxis (PEP). HVIB has been consulted by Occupational Medical Services for exposures occurring at NIH and has been instrumental in assisting in the construction of non-standard PEP regimens designed for specific exposures. [Corresponds to Project 4 in the April 2007 site visit report of the Host-Virus Interaction Branch, HIV Drug Resistance Program]